Failure to Perform Comprehensive Medication Regimen Review for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a licensed pharmacist performed a comprehensive monthly medication regimen review (MRR) for a resident with a diagnosis of type 2 diabetes mellitus. The resident, who had moderately impaired cognitive skills and was dependent on staff for daily activities, was admitted and readmitted with a history of diabetes and hyperglycemia. Despite this, the MRR for the relevant month only included a recommendation regarding gabapentin and did not address the absence of diabetes medication. The pharmacist did not review the resident's full list of diagnoses, previous medication orders, hospital records, or laboratory results, and therefore did not identify the lack of diabetes medication. Interviews revealed that the consultant pharmacist did not have access to the resident's complete diagnoses and only reviewed certain records if clarification was needed, rather than as a standard practice. The Director of Nursing confirmed that the pharmacist did not conduct a comprehensive review as required by facility policy, which mandates access to residents' medical records and a thorough monthly review. As a result, the resident did not receive necessary diabetes medication, leading to an episode of hyperglycemia.